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Selectively Reducing a Twin Pregnancy to One???

How do you decide to selectively reduce a multiple birth to a singleton?

I read this article in the New York Times, The Two-Minus-One Pregnancy, by Ruth Padawer a year ago and have thought about it often since. This paragraph, in particular, has played over and over in my head.

“Things would have been different if we were 15 years younger or if we hadn’t had children already or if we were more financially secure,” [Jenny, a 45 year old woman who reduced her twin pregnancy to a singleton] said later. “If I had conceived these twins naturally, I wouldn’t have reduced this pregnancy, because you feel like if there’s a natural order, then you don’t want to disturb it. But we created this child in such an artificial manner — in a test tube, choosing an egg donor, having the embryo placed in me — and somehow, making a decision about how many to carry seemed to be just another choice. The pregnancy was all so consumerish to begin with, and this became yet another thing we could control.”

Selective reductions are the little talked about “secret” of infertility medicine. In the past this technique was used almost exclusively to reduce higher order multiple pregnancies (triplets, quadruplets, quintuplets, and more) to twins in order to save or improve the lives of at least two of the fetuses. And make no mistake, despite the media’s fawning over higher order multiples; these children often face a lifetime of significant health problems and suffering. (See my recent post Infertility Treatment Quintuplets Shouldn’t Have Been a Surprise and click on the blog of this family to see what these five babies and their parents have gone through since their birth.) Higher order multiple births are like playing with fire—it’s possible to get out unscathed, but often you get burned, and the ones who suffer the most are the innocent children.

Statistics on the number and type of pregnancy reductions are not available, but “Mount Sinai Medical Center in New York, one of the largest providers of the procedure, reported that by 1997, 15 percent of reductions were to a singleton. Last year, by comparison, 61 of the center’s 101 reductions were to a singleton, and 38 of those pregnancies started as twins. ” I haven’t seen any research on selective reduction from twins to singletons or any good data on who is making this choice, but from what I hear from woman it is often woman in their 40s who conceived twins through donor eggs. Given their age and life circumstances (on second marriage with children already, single, etc.) they believe that it is best for all concerned that they have only one child.

As Padawer said in her article:

[W]hat began as an intervention for extreme medical circumstances has quietly become an option for women carrying twins. With that, pregnancy reduction shifted from a medical decision to an ethical dilemma. As science allows us to intervene more than ever at the beginning and the end of life, it outruns our ability to reach a new moral equilibrium. We still have to work out just how far we’re willing to go to construct the lives we want. …

What is it about terminating half a twin pregnancy that seems more controversial than reducing triplets to twins or aborting a single fetus? After all, the math’s the same either way: one fewer fetus. Perhaps it’s because twin reduction (unlike abortion) involves selecting one fetus over another, when either one is equally wanted. Perhaps it’s our culture’s idealized notion of twins as lifelong soul mates, two halves of one whole. Or perhaps it’s because the desire for more choices conflicts with our discomfort about meddling with ever more aspects of reproduction.

I am left with such mixed emotions, as is evident from having stewed over this article for a year. I never intended to blog on this topic—quite frankly I was too conflicted, too disturbed, and too scared about stirring up a controversy. However, I recently posted on another ethically confusing topic for me (Are Uterus Transplants Ethical, Moral, Reasonable, or What?!?), and I found the thought provoking responses I received to be extremely helpful. So, I decided to turn this perplexing topic over to the Creating a Family community to gather your thoughts. Maybe you can bring me more clarity.

At this point all I know for sure is that the infertility medical community needs to do everything in their power to reduce twins in general, and especially in woman who know from the beginning that they only want a singleton pregnancy. This fact should be taken into account when the decision is made on how many embryos are transferred—especially when donor eggs are used given the higher likelihood of pregnancy.

P.S. One of the off shoots of the secrecy surrounding selective fetal reduction, regardless if you are reducing to twins or triplets (or a singleton), is that women facing this decision feel very alone and often have a hard time finding any accurate information to help them. Creating a Family has a page of information on selective reduction available for patients, including a podcast with Dr. Mark Evans, who is a pioneer on this procedure and is quoted extensively in the NYT article mentioned in this blog.

The attitude of the woman in the article is not at all consistent with the attitude I have experienced in dealing with women using donor eggs. There is undisputed evidence that the risks of long term health issues for all fetuses increase dramatically with each additional fetus in the womb. Typically I believe the high order multiple births are often due to non-IVF fertility treatments rather than doctors transferring too many embryos (I think less than 3% of pregnancies from IVF cycles in the US result in triplet or more – meaning 1% of total IVF cycles that result in triplets or more). For what it is worth, I personally have had at least 3 clients who transferred two and ended up with triplets (one split). In each case they carried the triplets, but all were born far too early and spent significant time in the NICU at tremendous expense to the family and risk to the babies. Just a few days in the NICU can cost hundreds of thousands of dollars (or your percentage of that if you are insured), imagine what 10+ weeks in the NICU would cost along with all of the therapies and futher treatments that are often necessary for years thereafter. It is a very difficult decision to make – sacrifice one for all or potentially compromise all. My heart goes out to anyone who is in that situation.

Dawn, do you have any data on negative outcomes for twins vs trips, quads, etc? Is there at least some medical consensus that outcomes are much better for twins than higher multiples, and that’s why we’re focusing on reducing twins to a singleton?

Dawn, like I said above, I disagree with reduction but also think that the dr’s helping “create” the 5+ pregnancies should be held accountable too. I think it’s very sad that a couple could have to be faced with such a decision to begin with. I would understand their concern though when they have a high number of implantations through this. Yes, I would be concerned for the babies……….but really, who is able to decide which twin lives and which dies………which life is more viable and capable than the other?

I think implanting more than 2 or 3 eggs is irresponsible on the Drs part. Look @ Kate Gosselin & Octomom. They both insisted on more eggs & the Drs did it because that is what the patient wanted. @ least both women said no 2 reduction.

Unfortunately egg donor pregnancy or not, they did choose 2 have children in this way. I wld be so mad if I donated eggs 2 find out there was a twin reduction. In CT u can choose 2 be in touch with the family during the process.

I’m against it as well. Even trip’s and quad’s………I think RE’s that transfer more than 2 should be fined/restricted………..yes, that still leaves a chance for identical trips/quads or 2 sets of twins, etc………..but I think that reduction is not the answer.

Very little attention has been paid to the legitimate medical risks to mother and children in twin pregnancies. The concept that selective reduction was only medically advisable in higher orders of multiples has since been rescinded by the very doctor that made the initial determination. And not all fertility treatments utilize IVF, so it cannot always be as simple as transplanting one egg to avoid an unwanted twin pregnancy.

Find a NICU nurse or physician and ask them; they’re the ones that spend the most time with newborn twins. The reasons to consider a selective reduction to a singleton pregnancy are more than valid. The biggest shame is how poorly those reasons are communicated to expectant parents before the multiple children are carried as close to term as is possible.

Mike, you’re preaching to the choir on the underreported dangers of twin pregnancies, however, I think the real shame is that infertility patients don’t always understand the ramifications of the riskier treatments such as medicated IUIs with injectable ovulatory stimulating drugs. Most people I talk with still seems to think that the problem of higher order multiples is primarily with IVF.

Hi from ICLW. Given my age and medical conditions if I were pregnant with more than twins and if any of their lives were in danger due to the fact of having multiples I would selectively reduce the pregnancy. Not because of finances but because of health concerns.

Oh yeah, Anon, that gives me the willies too. I just keep in mind that that particular person may not be the norm. Or, she might have been doing a bit of rationalization. Also, we don’t know where the quote was cut. Might the next line have been, “and I wish I hadn’t fallen into that consumerist viewpoint trap”? Or “and we’ve never looked back”?

I guess I am really bothered by the attitude of the woman in the article. She states that if they were in a different place in their lives – they would not reduce. My feeling is – don’t go there knowing you could have multiple children if you are not in the right place in your life. I feel like more and more people are trying to order their children off a menu (this goes for adoption as well – where healthy young females are in higher demand).

I am also bothered by the idea that if these were the woman’s natural twins she would not reduce. Something about that just seems wrong. She values the artificially created children less? I’m not sure I would want to be her child.

When I was doing treatments I spoke at length with my RE about reduction. In the end I had decided that triplets or more would likely result in reduction to twins for me but I was not looking forward to actually having to do it. At the time twins would have been perfect. We ended up not going much further (injectible IUI cycle) and opted to adopt.

Oh, this might take a while…
I hadn’t seen this article, so I just followed the link back to it.

I think this article makes some interesting points, but I’m not convinced that this is any different from a medical or ethical standpoint than abortion. I hold some baseline assumptions and viewpoints that I use to get there, and indeed to support my belief that abortion should be available. If it helps, here they are:
– a fetus isn’t a person. This does not mean that termination should be taken lightly, but it is important to understand that this is one of my baseline views
– every pregnancy has an element of risk to it
– every twin pregnancy has an increased risk of health complications for the mother and the children
– during a pregnancy, except in rare cases, the best person or people to judge a given situation in terms of “best interest of the child” is the expectant parents
– the societal rules shouldn’t be changed on someone just because they need assistance becoming pregnant. If it is accepted that women who conceive naturally can make choices based on their ability to handle a newborn/toddler/etc. then that should also be accepted for those who require medical intervention

One of my friends had to go through selective reduction from triplets to twins, and it causes her great anguish to think of her lost fetus even though it likely saved the lives of its brothers. I don’t imagine that many people make the decision with glee and that they don’t wonder who the terminated fetus might have become. In the end, I must trust that people who make this choice have gotten the counseling, done the homework, searched their hearts, cataloged their resources, etc. in order to get to this point. With that, I have to say that if reliable, safe technology is available to enable it, I won’t stand against those who feel they need to draw upon it. At the same time, pre-treatment counseling and endorsements of good practice within the RE community regarding numbers of embryos transferred, etc. should certainly be encouraged. Hopefully that can reduce the likelihood that people are faced with this choice and the medical risks posed by the reduction itself.

What I don’t see in the post or the comments is any implications for the children born from a “reduced” pregnancy. I think it’s highly likely that the resulting child could have anger or even feelings of survivor guilt toward the parents who electively chose to destroy an “extra” fetus. While most parents may not decide to tell a child about this, it’s still possible for a relative to share a secret or for the child, as an adult, to find old medical records, emails, journals or the like upon the death or incapacity of an older parent. Eventually most of the paperwork of our lives is left to our adult children to sort and dispose of one we need a a nursing facility or die. This is a devestating time to learn that you were actually adopteded and causes severe pain,

Terri, yes it would be an unbelievably agonizing decision regardless how many are being reduced or to what number. For the record, the doctor usually makes this decision based on position or health of the fetus. However, if their is no medical preference on which to reduce, some doctors will let the patient choose–often based on gender.

Sarah, yes, there is strong data to support that twin pregnancies have better outcomes than higher order multiples. With every additional fetus, the risk of poor outcome increases. However, I am not sure that is the reason most couples/women decide to reduce to one. From what I hear and from what the doctors tell me, most that reduce to a singleton pregnancy due so for “social” reasons…meaning they do not want to parent twins or they think that parenting twins would complicate their lives or the lives of their existing children to the extent that it is not something they would willingly take on. I hope that my choice of words does not seem to be demeaning to the seriousness that they analyze this decision.

Ugh, THAT article. I take issue with the sensationalist tone of it and broadly painting all of the expectant mothers as these materialistic, selfish, cold upper class women. And on the topic of abortion in general, I hate to heed any ground against choice. BUT. I am disturbed that anyone would willingly put themselves at risk for creating a life that they didn’t want and have to make a heavy decision that impacts their family so deeply. Particularly with donor eggs, when the odds are very good that both eggs will implant. (And it doesn’t help that getting pregnant via IVF can be a long, expensive process and that REs will advise their patients to transfer multiple embryos). I’m hesitant to legislate anything that gets down in the details about why a woman reduces or aborts a pregnancy, but under these particular circumstances – transferring too many eggs that had good odds of all implanting – yeah, I have a problem with this.

Terri, I don’t actually know that it is done more often with egg donors since these statistics aren’t available, but from the people I have spoken with and from the podcast we did with Dr. Mark Evans, it seems to me that it was most often with women in their 40’s pregnant using donor eggs.

I am 5 days into the 2WW on a donor egg cycle in which my RE recommended we transfer 2 embryos, and we did. I don’t know what the future holds and I will admit the thought of twins scares me but if that is what we get I will be grateful. But what infertility has taught me is that I cannot judge someone else’s choices. I have done a lot of things over the last 2 years that I never thought I would have done before I faced infertility. I think that the key to solving this problem is to address the economic issues of fertility treatment – take money out of the equation and this problem would go away in a flash. Until then, women and their partners face impossible choices.

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